Did NTG make it worse?

[HERBIE1]

Here's the scenario-

50 year old white male, called for chest pain.

PMH-Essentially only multiple ortho injuries 4 years ago. He was a LEO who was struck on duty by a truck, broke 38 bones, had shoulder and hip replacement. Extensive rehab.

Fire assist company with allegedly ALS capabilities on scene 10 minutes prior to our arrival, began treatment.

The report we got from the medic as we arrived- initial vitals 170/110, HR 120, RR 32. pulse ox on room air 97%. Pale, sweaty, Sinus Tach in lead 2(no 12 lead available) with no ectopy. Lungs clear and equal. The rest of his exam was unremarkable.

Meds- Analgesics and Lipitor, if memory serves

NKA

As I approach the PT, I note that his L arm is drawn up to his chest, his is extremely anxious, and confused. I also see that he is hyperventilating, with what appears to be anxiety, but quickly realize he is exhibiting a Cheyne Stokes breathing pattern.

The fire medic tells me that he gave 1 NTG for the chest pain, but my partner thought someone else(an EMT on the fire company) said they gave 3 NTG's.

I immediately do a quick neuro check, his L grip is indeed profoundly weaker, L leg is also weak, but he also has some residual leg impairment from his prior injuries. I see facial assymetry, and he has some expressive aphagia. Unable to perform the arm drop test- too confused, but no matter.

Wife says the patient has been complaining of headaches for several days, but onset of these symptoms was sudden, while watching TV. We perform ALS, and take him to a Stroke Center.

The fire medic realizes he completely missed the DX-now he claims that the neuro symptoms "just started". He claims the patient actually pointed to his chest with his left hand. I say "You mean with the arm that's already contracted and resting against the L side of the patient's chest? " I glare at the guy because I know he's full of crap. He later admits to me it never occurred to him this was a CVA in progress but in the same breath swears the neuro symptoms just started as we arrived.

The medic says he wants to ride with us to the ER- unusual, but fine with me. The man is clearly sick, but in no immediate danger of coding so the extra hands were not needed. 10 minute transport to ER, essentially unchanged.

I am sitting in the captains' chair, finishing the radio report enroute, and pantomime to the fire medic (out of eyesight of the PT) that I think he may have a brain stem infarct going on. His eyes get real big.

I find out the PT is good friends with someone at our firehouse, so I ask if he wants us call him. He says yes. The fire medic does an unusually thorough job of completing his patient report- (guilty conscience, CYA)

Our coworker arrives at the ER rather quickly, and we find out he and the fire medic work part time at another small department together. I tell him the story, and my coworker becomes irate. Apparently he does not think too highly of this fire medic's skills based on prior incidents at the other job. I can see why. The PT has an episode of transient hypotension in the ER, but stabilizes.

They do a quick CT, find no evidence of a bleed, so they proceed with the TPA. The patient regains some movement but not sensation, and the confusion and speech improve.

Subsequent CT's and MRI's reveal the patient has 2 areas of ischemia-posterior, and L temporal areas from what I was told. He continues with rehab today,

My coworker is livid. He is an EMTB, but is sharp enough to realize this was never a cardiac event, and wonders if the NTG exacerbated the ischemia and caused the hypotensive episode, wondering if the vasodilation of the NTG moved the clot. I explained it's not likely, but no matter.(Trying to defuse the situation since this coworker is known to have a quick trigger temper) He's ready to kill this fire medic for jeopardizing his friend. I try to ease his mind and explain briefly about the effects of NTG, it's half life, etc, but he's still really upset. I find out later that our PT was at a social event 5-6 hours earlier, said he didn't feel well(head ache, nausea, dizzy) and came home, so that the ischemia probably started awhile ago.

A few days later, our coworker tells us he confronted the fire medic. He wants to hear his side of the story. Of course the story changes now, but our coworker had already heard what really happened from us. The fire medic still asserts he only gave 1 NTG, and that the neuro symptoms were not initially present. Our coworker said he told the fire medic the hospital is running tests to see what medications could have caused the drop in BP, and/or precipitated the ischemia (total BS, but he wants to scare this kid) He's convinced this fire medic is in someway responsible for what happened. The kicker is that our coworker is a superior officer over that fire medic in their other job, so this could get interesting. He plans on pursuing this fire medic's clearly inadequate skills because he has been reprimanded in the past for medical issues.

So- my questions-

Why the Cheyne Stokes type breathing? He did not have the classic apnea period, but my partner and I agreed that's what it appeared to be.

Could an embolus indeed have initially been in the respiratory center and traveled farther along, causing the 2 other areas of ischemia? The areas of ischemia do not explain that respiratory pattern.

Could that NTG have caused the embolus to dislodge and migrate?

I honestly think the majority of the damage was already done before we arrived, and the patient's delay in recognizing the early S&S's were the real problem.

The ultimate kicker:

This fire medic actually told me he no longer wants to be a hose monkey-he's bored. He wants to come back full time to an ambulance. Not if I have anything to say about it. I actually laughed at him- I thought he was kidding.

[Bieber]

So- my questions-

Why the Cheyne Stokes type breathing? He did not have the classic apnea period, but my partner and I agreed that's what it appeared to be.

Could an embolus indeed have initially been in the respiratory center and traveled farther along, causing the 2 other areas of ischemia? The areas of ischemia do not explain that respiratory pattern.

Could that NTG have caused the embolus to dislodge and migrate?

I don't have time to type out a full reply, but I'd like to jump in real quick and say that I have read at least one article from the New England Journal of Medicine where nitroglycerin was shown to permit movement of a thrombus further down inside an artery in a patient with a cerebral infarct affecting the patient's vision.

Here's the article, I just googled it up real quick and found it so I'm not real certain as to how common this event is, if at all. I'd suggest looking further into the studies available regarding nitroglycerin and thrombus migration, but this should get you started.

http://www.nejm.org/doi/pdf/10.1056/NEJM199011153232018

[fiznat]

DRAMA..........

If there is an issue with this paramedic's medicine, pass it on to his medical control and have it investigated officially. There is already too much that gets passed around as suspicion and rumor. If there is a problem, give it to the people who deal with problems.

You will never know what effect 1 (or 3) doses of NTG would have on this *potential* stroke. It seems doubtful to me that it had any effect whatsoever, but I suppose there is some small possibility. NTG will decrease cardiac output, which will in turn reduce cerebral perfusion pressure.